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ICD-10 Guide
ICD-10 CodesS12.1

S12.1

Billable

Fracture of second cervical vertebra

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 S12.1 is a billable code used to indicate a diagnosis of fracture of second cervical vertebra.

Key Diagnostic Point:

The fracture of the second cervical vertebra, also known as the axis, is a significant injury that can result from high-impact trauma, such as motor vehicle accidents, falls from heights, or sports injuries. The axis plays a crucial role in the rotation of the head and neck, and its fracture can lead to severe neurological deficits, including paralysis or loss of sensation, depending on the extent of spinal cord involvement. Clinically, patients may present with neck pain, limited range of motion, and neurological symptoms. Diagnosis typically involves imaging studies such as X-rays, CT scans, or MRI to assess the fracture's nature and any associated spinal cord injury. Management may include conservative treatment with immobilization or surgical intervention, such as fusion or decompression, depending on the fracture's stability and the patient's neurological status. Complications can include chronic pain, instability, and neurological deficits, necessitating careful monitoring and follow-up.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in fracture types (e.g., stable vs. unstable fractures)
  • Potential for associated neurological injuries
  • Need for precise documentation of mechanism of injury
  • Variations in treatment approaches (surgical vs. conservative)

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the type of fracture (e.g., stable vs. unstable)
  • Lack of clarity regarding neurological assessments
  • Improper linkage between diagnosis and treatment codes

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Detailed documentation of initial assessment, imaging results, and treatment provided.

Common Clinical Scenarios

Trauma cases presenting with neck pain after accidents or falls.

Billing Considerations

Ensure thorough documentation of neurological status and mechanism of injury.

Surgery

Documentation Requirements

Operative reports must detail the surgical procedure, indications, and post-operative care.

Common Clinical Scenarios

Surgical intervention for unstable fractures or decompression due to spinal cord compression.

Billing Considerations

Document any intraoperative findings and post-operative complications.

Coding Guidelines

Inclusion Criteria

Use S12.1 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the injury's mechanism, type, and any associated conditions

Exclusion Criteria

Do NOT use S12.1 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22551CPT Code

Anterior cervical discectomy and fusion

Clinical Scenario

Used in cases of unstable fractures requiring stabilization.

Documentation Requirements

Operative report detailing the procedure and indications.

Specialty Considerations

Ensure alignment with surgical documentation and post-operative care.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of cervical spine injuries, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of cervical spine injuries, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the primary cause of S12.1 fractures?

The primary causes include high-impact trauma such as motor vehicle accidents, falls, and sports injuries.

How can complications from S12.1 be managed?

Complications can be managed through careful monitoring, rehabilitation, and, if necessary, surgical intervention to stabilize the spine.